小腿中段离断再植保留足的活动功能方法的探讨

目的：小腿中段离断再植保留足活动功能研究。方法：常规断肢再植的同时将离断肢体远段失刘经支配的肌组织切除,只保留肌腱,切取髂胫束条桥接远端肌腱和近端肌组织,术后即行足被动伸屈活动,同时做相应肌组织的主动收缩锻炼。结果：治疗3例,平均随访2年5个月。足背伸跖屈肌力达Ⅲ-Ⅳ,踝关节活动度接近正常,肢体短缩垫高鞋底后步态基本政治家。结论：本手术方法对小腱中段断肢再植保留足的伸屈活动是一较理想的治疗措施。     

前臂中段离断伤再植保留手功能及加强肌力的方法

目的探讨前臂中段离断伤再植保留手功能及加强肌力的方法。方法断肢再植时将离断肢体以远失神经支配的肌肉组织切除,切取髂胫束条桥接远端肌腱和近端肌肉组织,并桥接肱二头肌加强屈腕屈指,桥接肱三头肌加强伸腕伸指功能,同时完好地接神经,以恢复手的感觉和手内在肌肌力。结果共治疗4例,术后随访19个月～28个月,平均24个月。平均肌力屈腕屈指M4;伸腕伸指M4。腕平均活动度屈腕60°,伸腕48°,桡偏20°,尺偏40°,手指总活动度（TAM）2例属优,2例属良,TAM＞80%。手部感觉恢复至S     

前臂中段断肢再植后期手部功能重建

为探讨前臂中段断肢再植后期手部功能重建,将肢体远端失神经支配的变性粘连组织切除,只保留远端的肌腱,肢体近端正常肌组织分离,切取髂胫束条桥接远侧肌腱和近端肌组织,治疗3例,随访时间平均21（19－24）个月,屈腕屈指,伸腕伸指肌力可达Ⅲ^ －-Ⅳ^-,有一定的抓,握,捏功能,本方法治疗效果确定,值得一用。     

髂胫束条桥接修复前臂中段背伸肌群损伤

目的 :解决前臂中段背伸肌群损伤而引起变性、粘连、挛缩 ,影响屈腕、屈指功能。方法 :将损伤以远失神经支配的肌肉切除 ,切取髂胫束条桥接远端的肌腱和近端的肌组织 ,术后即可行手指、腕关节被动伸屈活动 ,在被动伸掌指、伸腕同时做主动伸腕伸指肌的收缩锻炼。结果 :1978起治疗 7例 ,随访 5例 ,随访时间 18～ 2 9个月 ,平均 2 4.5个月 ,伸腕伸指关节肌力Ⅲ～Ⅳ级 ,获得较理想的伸屈功能。结论 :该方法充分利用近断端的正常肌组织伸缩效应 ,通过髂胫束条桥接远端的肌腱 ,发挥伸腕伸指功能 ,避免损伤肌肉的变性、粘连 ,伸腕、伸指及屈腕、屈指功能障碍 ,减少再次手术 ,是一种行之有效的治疗方法。     

髂胫束及缝匠肌移位治疗股四头肌损伤

目的：解决股四头损伤而引进变性、粘连、挛缩、肌力减弱。方法：将损伤远失神经支配的肌肉切除,切取髂胫束条桥接远端的肌腱和近的肌组织,游离缝匠肌下３／５段或２／３段止点不切断前移,加强股四头肌肌力,术后即刻行膝关节被动伸国能锻炼。结果：治疗单纯股四头肌损伤５例,股骨干骨折合并股四头肌伤６例,全部随访,随访时间１３～３２个月,平均２１个月。关节匀活动度１２０°,伸膝肌力ＩＶ＾＋级,结论：该方法恢复膝关节伸屈功能,避免发生膝关节伸直型僵硬,是一种行之有效的治疗手段。     

代股四头肌手术的并发症及预防

股四头肌瘫痪是小儿麻痹后遗症常见的病废,其发生率约为68.4％,该肌瘫痪后膝关节失去动力和稳定性,跛行、易跌跤、站立和行走都有很大困难。通过肌腱转移加强或代替股四头肌,恢复自动伸膝力量,方法很多,常用的有股二头肌、半腱肌、半膜肌、缝匠肌、股薄肌、阔筋膜张肌、腹外斜肌、腹直肌和髂腰肌等,而股二头肌与半     

改良式肌腱转位矫治股前型儿麻膝反屈

改良式肌腱转位矫治股前型儿麻膝反屈李世德⒇近年来我科应用股二头肌腱、髂胫束和半腱半膜肌、内收肌经股骨髁后方交叉固定，同时行股前肌力重建矫治小儿麻痹后遗膝反屈１５例，现将结果报告如下：１临床资料一般资料：本组１５例１７个肢体，男１０例，女５例，年龄７～...     

股二头肌移位代半腱肌矫正儿童小腿外旋畸形

股二头肌移位代半腱肌矫正儿童小腿外旋畸形北京市儿麻矫治中心（１０００２４）秦泗河小腿外旋是儿麻后遗症常见畸形，其发生的主要原因是髂胫束挛缩和股二头肌肌力大于半腱、半膜肌肌力，既往矫正术式是髂胫束松解或加作胫腓骨的内旋截骨术。作者自１９８８年来，采用股...     

背阔肌皮瓣游离移植修复前臂重建功能

创伤致前臂屈肌或伸肌并皮肤广泛缺损,使患肢手部完全丧失功能,治疗上极为困难。我院从1987年开始应用吻合血管、神经的背阔肌肌皮瓣移植,修复前臂肌肉并广泛性皮肤缺损4例。术后随访6个月～3年,肌力恢复4级左右,外形和功能满意。 我们的方法是将背阔肌的腱性部分固定在肱骨内髁或外髁上,远端分成束,每一束与手指肌腱的远侧断端在张力下缝接。同时可应用肌腱移位重建1～2指功能以弥补背阔肌肌力的不足。对背阔肌修复前臂软组织缺损重建功能的优缺点、受区的准备、肌腱的处理等问题进行了讨论。     

指动脉逆行桥接再植旋转撕脱性断拇指

拇指旋转性撕脱性离断的再植比较复杂。 1996以来 ,我科共收治拇指旋转性撕脱伤离断 6例 ,经用指掌侧固有动脉逆行桥接于拇指桡掌侧动脉后再植 ,获得成功。一、资料与方法　　 1.一般资料 :本组共 6例 ,男 4例 ,女 2例 ;年龄 8～ 40岁。致伤原因 :三角带绞伤 4例 ,钻床绞伤 2例。右拇指 5例 ,左拇指 1例。离断平面均在掌指关节。拇长伸肌腱从腱扩张部离断 2例 ,自肌腹抽出 4例。拇长屈肌腱均从近端肌腹抽出。　　 2 .手术方法 :臂丛麻醉下 ,按常规彻底清创后 ,先作骨架固定 ,修复关节囊。继之 ,修复伸肌腱 ;伸肌腱在扩张部断裂者直接作对端…     

The study and correction of human gait by electrical stimulation

To gain a better understanding of the functions that the calf and vastus muscles perform in the human walking gait the author systematically increased the contractions of these muscles separately and in combination by applying Functional Electrical Stimulation (FES) to them, during walking tests performed by a subject with nonpathological gait, and a patient with a hemiplegic gait. A four-channel stimulator was used with foot switch activated control systems, which accurately sequenced the FES pulses and timed them in relation to the footswitch contacts. In normal gait FES applied to the calf muscles in the first third of the stance phase induced knee extension, but when applied later in the stance phase it increased the amount of plantar flexion and knee flexion at the push off. Strengthened vastus muscle contraction increased the amount and duration of stance phase knee extension, and interacted with the calf FES to increase the amount of heel rise at the push off. In the hemiplegic gait calf FES resulted in some increased knee flexion and ankle plantar flexion after the opposite heel strike, but a persistent lower limb extensor synergy prevented knee flexion from occurring simultaneously with plantar flexion and a heel rise, while the hemiplegic limb was still weight bearing.     

Trans-tibial amputee gait: time-distance parameters and EMG activity

Gait analysis of trans-tibial (TT) amputees discloses asymmetries in gait parameters between the amputated and sound legs. The present study aimed at outlining differences between both legs with regard to kinematic parameters and activity of the muscles controlling the knees. The gait of 14 traumatic TT amputees, walking at a mean speed of 74.96 m/min, was analysed by means of an electronic walkway, video camera, and portable electromyography system. Results showed differences in kinematic parameters. Step length, step time and swing time were significantly longer, while stance time and single support time were significantly shorter on the amputated side. A significant difference was also found between knee angle in both legs at heel strike. The biceps femoris/vastus medialis ratio in the amputated leg, during the first half of stance phase, was significantly higher when compared to the same muscle ratio in the sound leg. This difference was due to the higher activity of the biceps femoris, almost four times higher than the vastus medialis in the amputated leg. The observed differences in time-distance parameters are due to stiffness of the prosthesis ankle (the SACH foot) that impedes the normal forward advance of the amputated leg during the first half of stance. The higher knee flexion at heel strike is due to the necessary socket alignment. Unlike in the sound leg, the biceps femoris in the amputated leg reaches maximal activity during the first half of stance, cocontracting with the vastus medialis, to support body weight on the amputated leg. The obtained data can serve as a future reference for evaluating the influence of new prosthetic components on the quality of TT amputee's gait.     

Ankle and knee coupling in patients with spastic diplegia: effects of gastrocnemius-soleus lengthening

BACKGROUND: Empirical observations of subjects with an equinus gait have suggested that there is coupled motion between the ankle and knee such that, during single-limb stance, the ankle moves into equinus as the knee extends. Since the gastrocnemius-soleus muscle-tendon unit spans both joints, we hypothesized that this muscle-tendon unit may be responsible for the coupling and that lengthening of the gastrocnemius-soleus muscle alone would result in greater ankle dorsiflexion as well as greater knee extension in single-limb stance, effectively uncoupling these joints. The concept that gastrocnemius-soleus lengthening may promote knee extension is counter to the popular notion that crouch gait may result if the hamstrings are not lengthened concomitantly. METHODS: A retrospective review identified thirty-four subjects with specific kinematic characteristics of equinus gait, and their gait was compared with that of normal children. Of the thirty-four subjects, eleven (twenty-two limbs) subsequently underwent isolated midcalf lengthening of the gastrocnemius and soleus muscles with use of a recession technique. Gait analysis including joint kinematics and joint kinetics, electromyography, and physical examination were performed to test the hypothesis. RESULTS: We found that, unlike the normal subjects, the patients with an equinus gait pattern had a positive correlation (r = 0.7) between ankle and knee motion during single-limb stance. As hypothesized, ankle plantar flexion occurred while the knee moved into extension during single-limb stance. Calculations of the lengths of the gastrocnemius-soleus muscle-tendon units showed them to be short throughout the gait cycle (p < 0.0001). After gastrocnemius-soleus recession, peak ankle dorsiflexion (p < 0.001) and peak ankle power (p < 0.001) shifted to occur later in stance than they did in the preoperative gait cycle. Furthermore, the magnitude of peak power increased (p < 0.001) in late stance despite the added length of the gastrocnemius-soleus muscle-tendon unit. The electromyographic amplitude of the gastrocnemius-soleus was reduced during loading (p < 0.02), and this finding, together with the kinetic changes, suggested that muscle tension was reduced. Changes at the knee were less pronounced but included greater knee extension at foot contact (p < 0.01). No increase in the knee flexion angle or extension moment occurred in midstance after the surgery. CONCLUSIONS: Patients with an equinus gait pattern function with a shortened gastrocnemius-soleus muscle-tendon unit, and this results in coupled motion between the ankle and knee during single-limb stance. Lengthening, with use of a recession technique, shifted ankle power generation and dorsiflexion to a later time in stance with no tendency to increase midstance knee flexion. Knee extension did increase at foot contact, but excessive midstance knee flexion persisted and was likely due to concomitant contracture of the hamstrings.     

Soleus and gastrocnemius muscle loading decreases anterior tibial translation in anterior cruciate ligament intact and deficient knees

This study evaluated the effect of the gastrocnemius and soleus muscles on dynamic knee stability by studying the effect of passive calf muscle loading on anterior tibial translation in normal and anterior cruciate ligament (ACL) deficient knees. Anterior tibial translation was measured bilaterally in 12 anesthetized patients with unilateral ACL-deficient knees using a KT-1000 arthrometer. An ankle-foot orthosis was used to passively dorsiflex the ankle and generate tension in the calf muscles. As the ankle flexion angle was progressively changed from 30 degrees plantar flexion to 10 degrees dorsiflexion, anterior tibial translation decreased 43% and 37% with manual maximum force in normal and ACL-deficient knees, respectively (P < .0001). These findings suggest that the calf muscles may function as dynamic knee stabilizers. Anterior tibial translation also was measured in four cadaver knees. Significant decreases were seen in anterior tibial translation with progressive ankle dorsiflexion in ACL-intact specimens and after the ACL had been cut (P < .05). This effect persisted when the gastrocnemius muscle was cut, but was lost when the soleus muscle was released. The data suggest that the soleus muscle may play a role in dynamically stabilizing the knee.     

Unterschenkel-Muskelatrophie bei Arthrose des oberen Sprunggelenks und deren Rehabilitation nach Implantation einer Sprunggelenksprothese

The aim of this orthopaedic-biomechanical study was to evaluate lower leg muscle function in ankle osteoarthritis (OA) patients and muscle rehabilitation after the implantation of a total ankle replacement (TAR). Patients with a severe unilateral ankle OA were assessed with an orthopaedic and biomechanical examination before and one year after TAR surgery. Visual analogue pain score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, ankle range of motion for dorsi- and plantar flexion (ROM DF/PF), and calf circumference difference between affected and contralateral healthy leg were measured. Isometric maximal voluntary torque for ankle dorsiflexion and plantar flexion were measured simultaneously with surface electromyography (EMG; mean frequency and intensity) of the anterior tibial, medial gastrocnemius, soleus, and peroneus longus muscle. Data were compared to a group of age- and gender-matched normal subjects. The mean calf circumference difference between legs did not significantly decrease from preoperative to one year follow-up. The mean dorsiflexion torque and plantar flexion torque of the affected ankle increased significantly. The atrophic muscles were characterized by a reduction of the mean EMG intensity and mean EMG frequency. In the rehabilitation process, the mean EMG intensity recovered and was not significantly different for all muscles, however, not for EMG frequency, which remained low and unchanged. This study reports for the first time in the literature the clinical and biomechanical facts of lower leg muscle atrophy in ankle OA as well as the amount of the muscle rehabilitation after a total ankle replacement. Patients with a symptomatic ankle OA achieve better function with a total ankle replacement; however, one year after the operation neuromuscular and biomechanical deficits may still be present.     

Flexion strength of the toes in the normal foot. An evaluation using magnetic resonance imaging

Flexion of the toes may be active from muscle contraction or passive from the reversed windlass function of the plantar aponeurosis. The aim of this study was to estimate the flexion moments the muscles of the foot and long digital flexors may be capable of generating and compare these calculations with published data.Magnetic resonance images were used to measure the maximal cross-sectional area of the foot muscles and long digital flexors, along with the radius of curvature of the metatarsal heads. Using known physiological data the maximal flexion moments the muscles may be able to generate at the metatarsophalangeal (MTP) joints were calculated.The methodology overestimates muscle strength and flexion moments at the metatarsophalangeal joints. The calculated maximal flexion moment at the 1st MTP joint is 4.27–6.84 N m, for the 2nd, 3rd and 4th MTP joints 3.06–4.91 N m, and the 5th MTP joint 0.47–0.75 N m.The flexion moments the muscles may generate at the MTP joints do not account for the flexion forces seen in normal walking. Given that maximal strength is not used in normal walking, we conclude that the reversed windlass mechanism of the plantar aponeurosis must be important in normal function of the toes.     

Tibialis posterior (TP) tendon transfer for foot drop: A single center experience

BackgroundFoot drop defined as a significant weakness of ankle and toe dorsiflexion. It leads to high stepping gait, functional impairment and deformity of the foot. Objective of this study was to assess the functional outcome of tibialis posterior (TP) transfer for patient with foot drop in a single center.MethodsThis is a retrospective study included 20 patients operated for foot drop of >1 year duration in the last 5 years. Preoperative assessment of muscles of all the three compartment of leg along with radiological assessment of ankle to rule out tarsal disintegration and ankle instability was done. Postoperatively gait, active dorsi/plantar flexion and the range of movement of the ankle and toes were assessed.ResultsTibialis posterior transfer was performed on 20 patients (16 males and 4 females, mean age 31.4 years). Commonest cause of foot drop was Hansen’s disease followed by post traumatic peroneal nerve damage and post injection sciatic neuropathy. At mean follow-up of 2 years, all patients, except one, could walk with heel-toe gait without any orthotic support. There was no pain, ruptures or infections of the transferred tendons. 19 of the 20 operated ankles had mean active dorsiflexion of 7.5°, the active plantar flexion of 36.25°, and the total range of movement 43.75°. The active dorsiflexion of the toes ranged from 5-20°.ConclusionDynamic tibialis posterior transfer gives good results in terms of normal gait, high patients’ satisfaction with minimal donor site morbidity and low complication rate.     

Muskuläre Biomechanik in der Sprunggelenkprothetik

The purpose of this orthopaedic-biomechanical study was to evaluate the muscle function in total ankle replacement (TAR) patients 1 year after surgery. Ten patients underwent a combined clinical and muscle biomechanical assessment prior to implantation and at the 1-year follow-up. Pain score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, ankle range of motion (ROM), and calf circumference difference between the affected leg and contralateral healthy leg were assessed. Biomechanically, isometric maximal voluntary torque for ankle dorsiflexion and plantar flexion was measured simultaneously with surface electromyography of four lower leg muscles.At follow-up, a significant improvement of the pain score (from 6.7 to 0.8 points), AOFAS ankle score (from 35.6 to 92.3 points), and ROM could be shown. Not significantly, the mean calf circumference difference between legs decreased from 2.2 to 1.4 cm. However, a significant increase was seen in the mean dorsiflexion (from 17.0 to 25.8 Nm) and plantar flexion torque (15.7 to 24.6 Nm) of the TAR-treated ankle. The mean EMG frequency content of the affected lower leg at TAR follow-up was lower than in the muscles of the contralateral healthy side. In contrast, the mean EMG intensity at TAR follow-up in side-comparison was statistically the same for all muscles.Ankle OA patients have better muscle function with TAR than under the arthritic condition, but they do not reach the normal level of the contralateral healthy leg 1 year after surgery.     

Pathophysiology of Charcot-Marie-Tooth disease

The etiology of the foot deformity in patients with Charcot-Marie-Tooth disease has not previously been discussed in relation to the extrinsic muscle function around the foot and ankle. Eight adult patients with a strong familial history were evaluated, and their foot findings were remarkably similar. All demonstrated a marked cavus deformity that was secondary to a forefoot equinus associated with contracture of the plantar fascia and a varus deformity of the calcaneus. The muscle function demonstrated marked weakness of the tibialis anterior and peroneus brevis muscles, whereas the peroneus longus and posterior calf muscles were rated as good to normal. Based on the relative strengths of these muscles and the progression of weakness, the authors hypothesize that the deformity observed in patients with Charcot-Marie-Tooth disease is secondary to the weakness of the tibialis anterior, peroneus brevis, and the intrinsic muscles, with their natural antagonists, the peroneus longus and the tibialis posterior muscles causing most of the deformity noted in these adult patients.     

Surgical treatment of knee dysfunction in cerebral palsy

The prerequisites for normal gait are: (1) stability in the stance phase of gait, (2) clearance of the foot in the swing phase, (3) proper foot preposition in swing, and (4) an adequate step length. In the stance phase, the knee provides shock absorption and energy conservation; in the swing phase, it allows foot clearance. To accomplish these functions, the knee must extend fully in stance and flex approximately 60 degrees in swing. Consequently, balanced muscle action at the hip, knee, and ankle joints, combined with adequate acceleration from the hip flexor and triceps surae muscles, is essential. In the crouch gait of spastic cerebral palsy, hamstring lengthening alone often converts the flexed-knee gait to an extended-knee, stiff-legged gait with inadequate swing-phase knee flexion. This unwanted conversion is due to cospasticity of the quadriceps and hamstring muscles. Restoration of normal knee function in patients with spastic paralysis is more successful when fractional hamstring lengthening is combined with a transfer of the distal rectus femoris tendon to either the iliotibial band or the distal tendon of the semitendinosus.